Remicade denied

lol @ manufacture picking up the tab. I wouldn't.

I'll tell you how it goes. They make a product, they price it so skkkkyyyyy high that everything is profit now.

Theeeen, the insurance says, we'll cover you 90%, but 10% you have to take care off. So you call Remicade and say, I make this much per year, I have a kid and two dogs...yadayayada...they go, sure sure, we'll eat the 10%, so you effectively pay 0%.

So you're happy and the Remicade crew is happy too. They made BOSS money of the 90% of the insurance. Better to make 90% out of 100% than 0%.

However, they eating the full tab and not making money??! Bad business practice.

If you're able to make them eat the full tab come back here and explain it to me, so I can give you a *virtual hand shake*

But doesn't the Canadian health care system pick up part of the tab? So, in effect, Remicade or Humira wouldn't really be given away free to those who couldn't afford it, they would just settle for what the Candadian health care system pays.

We actually have a Provincial Health System here - Not a national coverage, so this would be like you guys having coverage provided through your individual states and not Federal.

Or at least I think we are Provincial!! Haha... It's something we don't always think about - we just have coverage so we go to the hospital or doctor when we're sick and don't think much else about it.

In Ontario at least and I assume the same would be in other provinces, we have both private and provincial health coverage plans to do with coverage for prescription medications. So either the pritve or the provincial picks up the tab for the majority of Remicade, and the remaining (about say $200-$500 per infusion) is counted as a deductible and the patient pays this. For me it worked out to about $250 every 8 weeks total cost. Your deductible is based on income. Private coverage costs monthly but makes for a lessor deductible.

So yeah - they always get their cash and we have some programs here that will cover the deductible for low income families and such.

If you are on a provincial plan, then our GI's have to fill out a special form saying that there is no other therapy that will work as it's technically not covered under the plan without special circumstances.

Anyway - DON'T quote me on all that cause I'm still scratching my head trying to think if we have a federal program that reimburses the provincial or something maybe... Like I said, most of us just go to the doc or hospital when we're sick and don't give it much thought other than when it's time to pay at the pharmacy.


The downfall to this system is you wait forever to get into a GI or any type of specialist etc... it can be a very long time depending on where you live - up to six months. My GI is currently 8 months for new patients. Oh and of course we pay for it through taxation anyway... High tax Country...

Post Edited (Canada Mark) : 4/17/2014 8:06:24 PM (GMT-6)

In Alberta I had to apply for Alberta Blue Cross to pay for my Humira (this is separate from Alberta Health Care but they are somewhat affiliated, everyone gets Albert Health Care but Blue Cross you have to apply for as it's an actual insurance) anyways, I pay 118.00 a month now for ABC (because my husbands benefits won't kick in for another month, but I can still keep my ABC when his insurance kicks in, and his insurance through work might not cover Humira, but they likely will cuz they cover Remi) anyway, 118.00 is for family (cuz there's the 2 of us, our kids are grown but it would cover our dependents 20 yrs old and under) if you required subsidy then it would cost 85 instead of 118 a month, but we don't qualify based on our income. Then I still pay another 25.00 co-pay to safeway pharmacy a month (which hubby's insurance will cover when it kicks back in).

Regardless, here in AB if you can't afford it, you don't get denied so I'm assuming our provincial government (Alberta Health Care/Blue Cross) covers if for you likely if you make less than around 50,000.00 per yr.

Insurance called me yesterday morning to confirm they have denied the Remicade, and told me Humira was the preferred drug. Later yesterday I had to pick up another prescription, so I ask the pharmacist if they could check to see what my cost would be, and guess what they said it came up as tier 4 not covered, I think someone is trying to drive me crazy. O_o

But I did get a call later from a Coordination Nurse and she has contacted the GI's office. Kind of a catch 22 going on the GI would like me to be on Remicade and next April I go on Medicare and they will pay for Remicade, but not Humira but till then my insurance wants to to pay for Humira but not Remicade. So I guess I'll just wait without holding my breath and hope everything falls in place.

garylouisville said...
But doesn't the Canadian health care system pick up part of the tab? So, in effect, Remicade or Humira wouldn't really be given away free to those who couldn't afford it, they would just settle for what the Candadian health care system pays.

Not a 100% sure because I know that Humira was sending it to me for free until my ABC kicked in, so basically if I couldn't afford ABC at any point then I think ABC likely would have covered Humira for me at some point...not sure cuz I was able to get ABC, but I know that Humira was sending all my pens to me for free, I just don't know how long they do that for.

Except my GI specified that financial situations wouldn't interfere with a patient that needs either biologic so to me it sounds kinda like if there was no way I could get ABC then Humira would take care of it, but maybe it means that ABC would never deny anyone from getting it even if they couldn't afford to pay for ABC.